The Science is Never Settled

In recent years–and even more so in the last 11 months–I have been hearing a lot of the “S” word lately.  And no, not the expletive that would actually very appropriately describe the last 11 months, but rather, references to science.

We have all heard the phrases “Follow the science.”  “The science is clear.” “The science is settled.” This might be said in reference to global warming, pandemic restrictions, or any number of hot button political issues–usually by a nonscientist, I might add.  Politicians and other policy makers must think their stance, claim, or proposal will stick if they just add the word “science” to the dialogue.  But as any real life scientist will tell you, the science is rarely if ever settled on just about anything. Ongoing experiments and studies reveal new information all the time, even about diseases, weather phenomenon and other entities we thought we fully understood.  And since much of the science rhetoric is focused on the pandemic I’ll share two examples of this from the medical world.

Breast cancer has been with us for millennia, described as early as 1600 BC; mammography has been available since the 1960s. Yet, as a medical community we still cannot agree on a standard set of screening recommendations. Do we start at age 40? Or 50?  Do we order one every year, or every other year? What about 3D mammogram versus standard technique? Scientific evidence does not always provide clear cut answers to our very basic questions when you carefully review the literature.

The same could be said for coronary artery disease.  If a patient has stable chest pain with exertion, is it better for them to receive medical management (aspirin, beta blockers, statins) or to go to the cath lab for an angiogram and a stent?  The answer to most people would seem obvious–the stent, of course; fix the obstruction and the patient gets better.  But large clinical trial after clinical trial (COURAGE, ORBITA, ISCHEMIA) suggests patients receiving medical management do better in all areas, including mortality, cardiovascular events, and exercise tolerance. Still, this approach seems unpopular and has not gained traction in clinical practice. Recently, many prominent journals and medical societies are questioning why; the American Journal of Medicine in 2020 published an opinion piece entitled, “Stop Stenting, Start Reversing Atherosclerosis.”  

To be clear: I am not saying give up on science or stop following the evidence. But if we can’t (or don’t) always do this for such common entities as breast cancer and heart disease, imagine how little we actually know about covid-19, the coronavirus syndrome that was named just one year ago this month. And think about how many scientific recommendations came and went during this time: don’t bother wearing a mask. Oh wait, everyone should wear a mask. Maybe even two!  Take hydroxychloroquine right away.  Or, perhaps not.  Currently, vitamin D supplementation appears to be gaining evidence, while high dose vitamin C is falling out of favor.

In the race to defeat the virus, scientists published almost 200,000 articles related to covid-19 in the year 2020.  That’s a lot of information in a short amount of time, and many of these articles need to be carefully reviewed for strengths and limitations in terms of how we actually apply them to patient care. As the database continues to expand in terms of numbers of patients we’ve treated or enrolled in clinical trials, more information will come and may shift the recommendations even further. And we’ve only just begun in terms of studying the effect of vaccines on the pandemic.

In a sense, this uncertainty is actually a good thing; continued scientific inquiry is needed and necessary to better understand our world, whether it relates to a novel disease such as covid-19 or something as ancient as cancer or tuberculosis.  Research and discovery are ongoing, never ending processes that continue to propel us forward in all areas of our lives.

The science is never settled, and that’s the way it should be. 

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